Male Circumcision is a surgical procedure that removes some or all of the foreskin (prepuce) from the penis. The word "circumcision" comes from Latin circum (meaning "around") and caedere (meaning "to cut").

Circumcision predates recorded human history, with depictions in stone-age cave drawings and Ancient Egyptiantombs. Theories regarding it include that circumcision is a form of ritual sacrifice or offering, a health precaution, a sign of submission to a deity, a rite of passage to adulthood, a mark of defeat or slavery, or an attempt to alter aesthetics or sexuality.

Male circumcision is a religious commandment in Judaism, expected in Islam, and customary in some Oriental Orthodox and other Christian churches in Africa. On the other hand, it is condemned as contrary to Christian practice for Gentile Christians by the Apostle Paul and some church councils. Circumcision is common in the Middle East, North America (U.S. and Canada), Australia, and parts of Africa and Asia, especially the Philippines and South Korea. According to the World Health Organization (WHO), 30 percent of men worldwide have had the procedure.

Opponents condemn male infant circumcision as a human rights abuse and a genital mutilation similar to female genital cutting, while advocates of circumcision regard it as a worthwhile public health measure. Although the medical justification for circumcision remains controversial, since March 2007, the WHO and other international organizations recognize male circumcision as an efficacious intervention for HIV prevention, while cautioning that it only provides partial protection and should not replace other interventions to prevent the transmission of HIV.[1]

Cultures and religions

The time of circumcision differs from culture to culture: either shortly after birth, during childhood or around puberty as part of a rite of passage. In terms of religion, it is most prevalent in the Jewish and Muslim faiths. It is less common in Europe, Latin America, China, and India.

Judaism

Abraham and Isaac. The covenant of circumcision was initiated through Abraham and carried on through his descendants, centering on Isaac.

Circumcision is a fundamental rite of Judaism, initiated as a sign of God's covenant with Abraham and his descendants. It is a positive commandment obligatory under Jewish law for Jewish males, and is only postponed or abrogated in the case of threat to the life or health of the child. It is usually performed in a ceremony called a Brit milah (or Bris milah, colloquially simply bris) (Hebrew for "Covenant of circumcision"). A mohel performs the ceremony on the eighth day after birth unless health reasons force a delay. According to the Torah (Genesis, chapter 17 verses 9-14), God commanded Abraham to circumcise himself, his offspring, and his slaves as a sign of an everlasting covenant:

God also said to Abraham: “On your part, you and your descendants after you must keep my covenant throughout the ages. This is my covenant with you and your descendants after you that you must keep: every male among you shall be circumcised. Circumcise the flesh of your foreskin, and that shall be the mark of the covenant between you and me."

According to Jewish law, failure to follow the commandment carries the penalty of karet, or being cut off from the community by God. Brit milah is considered to be so important that should the eighth day fall on the Sabbath, actions that would normally be forbidden because of the sanctity of the day are permitted in order to fulfill the requirement to circumcise. The expressly ritual element of circumcision in Judaism, as distinguished from its non-ritual requirement in Islam, is shown by the requirement in Orthodox tradition that a child who either is born aposthetic (without a foreskin) or who has been circumcised without the ritual must nevertheless undergo a Brit milah in which a drop of blood (hatafat-dam, הטפת דם) is drawn from the penis at the point where the foreskin would have been or was attached.

Christianity

"On the eighth day, when it was time to circumcise him, he was named Jesus… When the time of their purification… had been completed, Joseph and Mary took him to Jerusalem to present him to the Lord" (Luke 2: 21-22).

According to the Gospel of Luke, Jesus himself was circumcised on the eighth day. However, Christianity does not call for circumcision, especially as it pertains to Gentile Christians. Saint Paul was particularly adamant in his opinion against the circumcision of Gentile believers.

Was anyone called while circumcised? Let him not become uncircumcised. Was anyone called while uncircumcised? Let him not be circumcised. Circumcision is nothing and uncircumcision is nothing, but keeping the commandments of God is what matters (I Corinthians 7:18-19).

The original apostles and Christian believers were Jews, who practiced the commandment to circumcise their sons. However, a question arose as to whether or not Gentiles who accepted Jesus as the Messiah needed to be circumcised. The meeting between Paul and the senior apostles known as the Council of Jerusalem declared that circumcision was not necessary for Gentile believers. However, the council did not directly deal with the question of Jewish Christians circumcising their sons. St. Paul had his disciple Timothy circumcised (Acts 16:3). In Acts 21, Paul made a public act of purification in the Temple of Jerusalem to demonstrate that the charges against him—of teaching that Jewish Christians should not circumcise their sons—were untrue. Acts records the following instruction to Paul from James the Just, head of Jerusalem church and identified as "the Lord's brother:"

We (Jewish Christians in Jerusalem) have been informed that you teach all the Jews who live among the Gentiles to turn away from Moses, telling them not to circumcise their children… There are four men with us who have made a vow. Take these men, join in their purification rites and pay their expenses… Then everybody will know there is no truth in these reports about you (Acts 21: 20-24).

However, in his letters, Paul strictly warned Gentile Christians against adopting the practice of circumcision and downplayed its significance for Jews. Despite his statement in First Corinthians about the importance of keeping the commandments, in another of his letters Paul argued that keeping faith in Christ alone—not keeping the Jewish ceremonial laws—brought salvation.

After the destruction of the Temple in 70 C.E., Christianity took on a less Jewish character, and was soon to become an essentially Gentile religion, in which Paul's teachings against circumcision were the norm. Although some Christians still practiced it, at the Council of Basel-Florence in 1442, the Catholic Church condemned circumcision among the Copts and ordered against its practice. During the Spanish Inquisition, inspectors considered the circumcision of the sons of Jewish converts to Christianity to be evidence that the convert was insincere in his conversion, which was a capital crime.[2]

Nevertheless, some mainstream Christian traditions still keep a "Feast of the Circumcision," commemorating Jesus' own circumcision on the eight day after his birth. The Greek Orthodox Church celebrates the Circumcision of Christ on January 1, while those Orthodox churches following the Julian calendar celebrate it on January 14. The Russian Orthodox Church considers it a "Great Feast." In the Catholic, Anglican and Lutheran churches it has been replaced by other commemorations. Roman Catholics celebrate January 1 as the Solemnity of Mary, the Mother of God, and it remains a holy day of obligation.

Eastern Christians never wholly abolished the practice of circumcision, and the Abyssinians, living among largely Muslim populations, find it a useful hygienic precaution. It is also customary among the Coptic, Ethiopian, and Eritrean Orthodox Churches, and also some other African churches. In the U.S., most Protestants and many Catholics have their sons circumcised for hygienic reasons, and the practice has become increasingly common in Europe as well.

Islam

A troupe dancing at Sultan Ahmed III's 14-day celebration of his sons' circumcision in 1720. Miniature from the Surname-i Vehbi, Topkapı Palace, Istanbul.

The origin of circumcision in Islam is a matter of religious and scholarly debate. It is mentioned in some hadith, but not in the Qur'an itself. Some Islamic scholars hold that circumcision is recommended, others that it is obligatory.[3] However, no uncircumcised male may lawfully make the pilgrimage to Mecca, which is a required act of all Muslims capable of making the journey. [4] The timing of Muslim circumcision varies. Arabs traditionally performed the operation at the onset of puberty, and it is thought the Prophet himself was circumcised in this way. Turkish, Balkan, rural Egyptians, and Central and South Asian Muslims typically circumcise boys between the ages of six and 11. Traditionally, Turkish circumcisions are celebrated with sweets and the "Sünnet Düğünü," or "Circumcision Feast/Celebration." It is considered a very important celebration in man's life as a passage to manhood. However, in the middle-class, circumcision is more usually done in infancy.

In Pakistan, Muslims may be circumcised at all ages from the newborn period to adulthood, though the medical profession has encouraged circumcisions in the first week after birth to reduce complications.

In Iran, circumcision was traditionally practiced at the onset of puberty, but is now usually performed at the age of five or six for children born at home, or at two days old for those born in hospitals.[5] A Muslim Iranian boy must be circumcised by puberty if he is to participate normally in religious activities.

Other traditions

Circumcision is part of the initiation rites in some African, Pacific Islander, and Australian aboriginal traditions in areas such as Arnhem Land, where the practice was introduced by Makassan traders from Sulawesi in the Indonesian Archipelago.

A Dogon painting in a "circumcision cave."

In West Africa infant circumcision may have had tribal significance as a rite of passage. Today in some non-Muslim Nigerian societies it is medicalized and is simply a cultural norm. Among some West African animist groups, such as the Dogon and Dowayo, it is taken to represent a removal of "feminine" aspects of the male, turning boys into fully masculine males. In additional African societies, circumcision has become medicalized and is simply performed in infancy without any particular conscious cultural significance. Among the Urhobo of southern Nigeria it is symbolic of a boy entering into manhood. The ritual expression, Omo te Oshare ("the boy is now man"), constitutes a rite of passage from one age set to another.

For Nilotic peoples, such as the Kalenjin and Maasai, circumcision is a rite of passage observed collectively by a number of boys every few years, and boys circumcised at the same time are taken to be members of a single age set. Authority derives from the age-group and the age-set. Prior to circumcision a natural leader, or olaiguenani, is selected; he leads his age-group through a series of rituals until old age, sharing responsibility with a select few, of whom the ritual expert (oloiboni) is the ultimate authority. Masai youths are not circumcised until they are mature, and a new age-set is initiated together at regular intervals of 12 to 15 years. The young warriors (ilmurran) remain initiates for some time, using blunt arrows to hunt small birds which are stuffed and tied to a frame to form a head-dress.

Circumcision ceremonies among certain Australian aboriginal societies are noted for their painful nature, including subincision for some aboriginal peoples in the Western Desert.

In the Pacific, ritual circumcision is nearly universal in the Melanesian islands of Fiji and Vanuatu; participation in the traditional land diving on Pentecost Island is reserved for those who have been circumcised. Circumcision is also commonly practiced in the Polynesian islands of Samoa, Tonga, Niue, and Tikopia. In Samoa, it is accompanied by a celebration.

Circumcision in South Korea is largely the result of American cultural and military influence following the Korean War. The origin of circumcision in the Philippines is uncertain, with both western and Muslim influence being probable factors.

Ethical issues

Circumcising infants is controversial. Those advocating circumcision assert that circumcision is a significant public health measure, preventing infections, and slowing down the spread of AIDS. However some medical associations in the United States, Australia, and Canada do not recommend the routine, non-therapeutic circumcision of newborns.

Views differ on whether limits should be placed on caregivers having a child circumcised. Opponents argue that the medical benefits of circumcision are uncertain, and that removal of healthy genital tissue from a minor should therefore not be subject to parental discretion. Some also suggest that physicians who perform the procedure are not acting in accordance with their ethical duties to the patient, regardless of parental consent. Others argue that there is no convincing evidence of sexual or emotional harm in male circumcision, and that there are much greater monetary and psychological costs in circumcising later rather than in infancy.

Traditionally, circumcision has been presumed to be legal when performed by a trained operator. In 2001, Sweden allowed only persons certified by the National Board of Health to circumcise infants, requiring a medical doctor or an anesthesia nurse to accompany the circumciser and for anesthetic to be applied beforehand. Jews and Muslims in Sweden objected to the new law, saying it violates their religious rights. In 2001, the World Jewish Congress stated that it was “the first legal restriction on Jewish religious practice in Europe since the Nazi era.”[6] However, in 2006, the United States State Department reported that most Jewish mohels had been certified under the law and 3000 Muslim and 40 to 50 Jewish boys were circumcised each year.

The American Academy of Pediatrics (1999) stated "a survey of adult males using self-report suggests more varied sexual practice and less sexual dysfunction in circumcised adult men." In January 2007, The American Academy of Family Physicians (AAFP) stated: "No valid evidence to date, however, supports the notion that being circumcised affects sexual sensation or satisfaction." However, Boyle et al. (2002) argued that circumcision removes tissues with "heightened erogenous sensitivity."[7] They concluded that, "Evidence has also started to accumulate that male circumcision may result in lifelong physical, sexual, and sometimes psychological harm as well."

Medical aspects

The British Medical Association, states “there is significant disagreement about whether circumcision is overall a beneficial, neutral or harmful procedure. At present, the medical literature on the health, including sexual health, implications of circumcision is contradictory, and often subject to claims of bias in research.” Cost-benefit analyses have varied.

The risk in a competently performed medical circumcision is very low. According to the American Medical Association AMA, blood loss and infection are the most common complications. Bleeding is mostly minor; applying pressure will stop it. However, in poorly carried out circumcisions, complications from bleeding and infection can be catastrophic.

Observational studies in the 1980's identified a strong association of circumcision status and a reduced risk of HIV infection, as well as of sexually transmitted genital ulcer disease, although behavioral factors may have been a part of that association. A 2007 study made by the U.S. National Institutes of Health revealed "an approximate halving of risk of HIV infection in men who were circumcised" in Kenya and Uganda. These results support the findings of a French study of South African men published in late 2005, which demonstrated "at least a 60 percent reduction in HIV infection among circumcised men."[8]

Smegma—a combination of exfoliated epithelial cells, transudated skin oils, and moisture that can accumulate under the foreskin of males and within the female vulva area—is common to all mammals, male and female. In some cases, accumulating smegma may help cause inflammation of the glans. It also has a strong odor. Circumcision helps control the accumulation of smegma, but proper hygiene can also do this.

The American Academy of Pediatrics observes “There is little evidence to affirm the association between circumcision status and optimal penile hygiene.”[9] However, it also states that the "relationship among hygiene, phimosis (difficulty in retracting the foreskin), and penile cancer is uncertain." The Royal Australasian College of Physicians emphasizes that the penis of an uncircumcised infant requires no special care and should be left alone.

Circumcision procedures

Circumcision removes the foreskin from the penis. For infant circumcision in modern hospital procedures, clamps, such as the Gomco clamp, Plastibell, and Mogen clamp are often used. Clamps are designed to cut the blood supply to the foreskin, stop any bleeding and protect the glans. Before using a clamp, the foreskin and the glans are separated with a blunt probe and/or curved hemostat.

With a Gomco clamp, a section of skin is first crushed with a hemostat then slit with scissors. The foreskin is drawn over the bell shaped portion of the clamp and inserted through a hole in the base of the clamp and the clamp is tightened, "crushing the foreskin between the bell and the base plate." The crushing limits bleeding (provides hemostasis). While the flared bottom of the bell fits tightly against the hole of the base plate, the foreskin is then cut away with a scalpel from above the base plate. The bell prevents the glans being reached by the scalpel.

With a Mogen clamp, the foreskin is grabbed dorsally with a straight hemostat, and lifted up. The Mogen clamp is then slid between the glans and hemostat, following the angle of the corona to avoid removing excess skin ventrally and to obtain a superior cosmetic result, than with Gomco or Plastibell circumcisions. The clamp is locked shut, and a scalpel is used to cut the foreskin from the flat (upper) side of the clamp. The frenulum is cut if frenular chordee is evident.

With the Plastibell clamp, the foreskin and the clamp come away in three to seven days.

Early history of circumcision

It is possible that circumcision arose independently in different cultures for different reasons. It has been variously proposed that circumcision began as a religious sacrifice, as a rite of passage marking a boy's entrance into adulthood, as a form of sympathetic magic to ensure virility, as a means of suppressing (or enhancing) sexual pleasure, as an aid to hygiene where regular bathing was impractical, as a means of marking those of lower (or higher) social status, as a means of differentiating a circumcising group from their non-circumcising neighbors, as a means of discouraging masturbation or other socially proscribed sexual behaviors, to remove "excess" pleasure, to increase a man's attractiveness to women, as a symbolic castration, as a demonstration of one's ability to endure pain, or as a male counterpart to menstruation or the breaking of the hymen. It also has been suggested that the custom of circumcision gave advantages to tribes that practiced it and thus led to its spread regardless of whether the people understood this.

Circumcision in the ancient world

The oldest documentary evidence for circumcision comes from ancient Egypt. Tomb artwork from the Sixth Dynasty (2345-2181 B.C.E.) shows men with circumcised penises, and one relief from this period shows the rite being performed on a standing adult male. The Egyptian hieroglyph for "penis" depicts either a circumcised or an erect organ. The examination of Egyptian mummies has found some with foreskins and others who were circumcised.

In the aftermath of the conquests of Alexander the Great, Greek dislike of circumcision led to a decline in its incidence among many peoples that had previously practiced it. The writer of the 1 Maccabees wrote that under the Seleucids, many Jewish men attempted to hide or reverse their circumcision so they could exercise in Greek gymnasia, where nudity was the norm. First Maccabees also relates that the Seleucids forbade the practice of brit milah (Jewish circumcision), and punished those who performed it—as well as the infants who underwent it—with death.

Medical circumcision modern times

There are several hypotheses to explain why infant circumcision was accepted in the United States about the year 1900. The success of the germ theory of disease made surgery safer, and made the public deeply suspicious of dirt and bodily secretions. So smegma—which collects under the foreskin—was viewed as unhealthy, and circumcision was seen as good penile hygiene.

In 1855, the Quaker surgeon, Jonathan Hutchinson, observed that circumcision appeared to protect against syphilis.[10]

As hospitals proliferated in urban areas, childbirth, at least among the upper and middle classes, was increasingly under the care of physicians in hospitals rather than with midwives in the home. It has been suggested that once a critical mass of infants were being circumcised in the hospital, circumcision became a class marker of those wealthy enough to afford a hospital birth. The influence of Jewish doctors in the American medical professions has also been suggested.

By the 1920s, advances in the understanding of disease had challenged some of the original medical basis for preventive circumcision but doctors continued to promote it as good penile hygiene and as a preventive for balanitis, phimosis, and penile cancer.

Infant circumcision was taken up in the United States, Australia and the English-speaking parts of Canada and to a lesser extent in the United Kingdom and New Zealand. The British Royal Family had a long tradition requiring that all male children be circumcised. Although it is difficult to determine historical circumcision rates, one estimate of infant circumcision rates in the United States holds that 30 percent of newborn American boys were being circumcised in 1900, 55 percent in 1925, and 72 percent by 1950.[11]

Circumcision since 1950

In 1949, the United Kingdom's newly formed National Health Service removed infant circumcision from its list of covered services. Since then, circumcision has been an out-of-pocket cost to parents, and the proportion of newborns circumcised in England and Wales has fallen to less than one percent.

In Canada (where public medical insurance is universal, and where private insurance does not replicate services already paid from the public purse), individual provincial health services began delisting circumcision in the 1980s. The infant circumcision rate in Canada has fallen from roughly 50 percent in the 1970s to 13.9 percent in 2003. However, the figures varied from 29.5 percent on Prince Edward Island to zero in Newfoundland and Labrador.

In South Korea, circumcision grew in popularity following the establishment of the United States trusteeship in 1945 and the spread of American influence. More than 90 percent of South Korean high-school boys are now circumcised, but the average age of circumcision is 12 years.

Prior to 1989, the American Academy of Pediatrics had a long-standing opinion that medical indications for routine circumcision were lacking. This stance, according to the AMA, was reversed in 1989, following new evidence of reduction in risk of urinary tract infection. A study in 1987 found that the prominent reasons for parents choosing circumcision were "concerns about the attitudes of peers and their sons' self concept in the future," rather than medical concerns.[12] A 1999 study reported that reasons for circumcision included "ease of hygiene [67 percent], ease of infant circumcision compared with adult circumcision (63 percent), medical benefit (41 percent), and father circumcised [37 percent]." The authors commented that "Medical benefits were cited more frequently in this study than in past studies, although medical issues remain secondary to hygiene and convenience."[13]

A 2001 study reported that "The most important reason to circumcise or not circumcise the child was health reasons."[14] A 2005 study speculated that increased recognition of the potential benefits may be responsible for an observed increase in the rate of neonatal circumcision in the United States between 1988 and 2000.[15]

↑ Although the Academy's 1975 statement asserted that "A program of education leading to continuing good personal hygiene would offer all the advantages of circumcision without the attendant surgical risk," the 1999 statement cites a study which found that "appropriate hygiene decreased significantly the incidence of phimosis, adhesions, and inflammation, but did not eliminate all problems."

↑ J. Hutchinson, On the influence of circumcision in preventing syphilis, Medical Times and Gazette II (1855): 542–3.

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